donheff
Give me a museum and I'll fill it. (Picasso) Give me a forum ...
We are having fun talking about orgasms and prostate cancer over on a vitamin E thread but the new recommendation on the PSA test raise serious question that all of the men on this board will need to address. On a biking forum I frequent there is a good discussion going on but I would like to see what the smart folks over here are thinking (not that the bike crowd is dumb). 
So, if you can stand reading it here is a longish intro from my point of view quoting a couple of posts from the other forum. First this is the post that started the thread. It contains a link to the recommendations:
So, if you lasted this far, what do you think about how we should deal with this dilemma?
So, if you can stand reading it here is a longish intro from my point of view quoting a couple of posts from the other forum. First this is the post that started the thread. It contains a link to the recommendations:
Current "draft" recommendation by the US Preventive Services Task Force for PSA testing is to do away with it for men under 75.
"The common perception that PSA-based early detection of prostate cancer saves lives is simply not supported by the scientific evidence," task force co-vice chair Michael L. LeFevre, MD, MSPH, professor of family and community medicine at the University of Missouri, tells WebMD.
Read the draft recommendations here.
Your thoughts?
After a lot of back and forth I weighed in with my summary of the recommendations (no naked links):"The common perception that PSA-based early detection of prostate cancer saves lives is simply not supported by the scientific evidence," task force co-vice chair Michael L. LeFevre, MD, MSPH, professor of family and community medicine at the University of Missouri, tells WebMD.
Read the draft recommendations here.
Your thoughts?
After all this back and forth about what the "study" said I read the linked article (It isn't a study, it is a recommendation based on a lot of studies). What it says (or at least what I think it says) can be distilled to this. Most men who get a positive PSA test will go on to get a biopsy. But about 80% of those results are false positives so those guys get the negatives of a biopsy for naught. Of those whose biopsies show a cancer almost all of them will have treatment even though though most of the cancers would progress slowly and never have resulted in clinical symptoms before death from other causes. The aggressive or otherwise dangerous cancers will be detected later by clinical symptoms and would then be treated anyway. So the net result of screen is a lot of angst and earlier treatment of some cancers. It is those few guys who will get the earlier treatment of dangerous tumors that we are concerned with and why some of us have supported getting the screen. BUT, the statistics show that the benefits are minimal or none. The studies found NO advantages from screening for men over 70. And the studies showed marginal if any benefits for men 59-70. From the recommendation: "The evidence is convincing that for men aged 70 years and older, screening has no mortality benefit. For men aged 50 to 69 years, the evidence is convincing that the reduction in prostate cancer mortality 10 years after screening is small to none." If all of this is accurate then most (maybe not all) of the guys who got early treatment due to the test/biopsy would have gotten treatment later due to clinical syptoms and would end up with a similar result. The recommendation is to rely on clinical symptoms, not PSA screening to counsel a biopsy and subsequent treatment if a cancer is found. They are saying YOU are better off waiting for symptoms before getting a biopsy. This is not a cost tradeoff it is a straight benefit to you recommendation. Here is another quote:
I plan to talk to my primary care physician about this at my next physical. My inclination would be to skip the PSA screen and rely on clinical symptoms. But I would be open to a rational discussion about why I might be wrong.
Tons of debate followed by a good post from a doctor:"The common perception that PSA-based early detection of prostate cancer prolongs lives is not supported by the scientific evidence. The findings of the two largest trials highlight the uncertainty that remains about the precise effect that screening may have, and demonstrate that if any benefit does exist, it is very small after 10 years. The European trial found a statistically insignificant 0.06% absolute reduction in prostate cancer deaths for men aged 50 to 74 years, while the U.S. trial found a statistically insignificant 0.03% absolute increase in prostate cancer deaths (6, 7). A meta-analysis of all published trials found no statistically significant reduction in prostate cancer deaths (10). At the same time, overdiagnosis and overtreatment of prostatic tumors that will not progress to cause illness or death are frequent consequences of PSA-based screening. Although about 90% of men are currently treated for PSA-detected prostate cancer in the United States—usually with surgery or radiotherapy—the vast majority of men who are treated do not have prostate cancer death prevented or lives extended from that treatment, but are subjected to significant harms."
From a money perspective it seems like the test simply pumps money into the medical system with no evidence that the money makes a difference. Since the advent of testing a million men have had surgeries/radiation who would not have had them otherwise: "From 1986 through 2005, PSA-based screening likely resulted in approximately 1 million additional U.S. men being treated with surgery, radiation therapy, or both compared with before the test was introduced."I plan to talk to my primary care physician about this at my next physical. My inclination would be to skip the PSA screen and rely on clinical symptoms. But I would be open to a rational discussion about why I might be wrong.
What you need to know about studies like this one on the value of PSA testing is that they draw their statistical conclusions from populations rather than individuals. This allows the researchers to conclude that routine PSA screening for cancer in "younger" individuals doesn't show much "benefit" (again in terms of population outcomes) compared to the "cost" and/or "risk" of such screening. The study seemed to be well-designed and analyzed. What does that mean for you as a guy who wants to catch a prostate Ca early when it could be cured? Actually, it means very little, because the study deals with "population" risks/benefits.
The PSA is a simple blood test. It costs money (about $100 for the test plus some more for the doctor visit). A negative test doesn't absolutely exclude prostate Ca, but for all practical purposes it does exclude it. A high PSA (>5) level is suggestive of Ca, but could be due to relatively benign things like prostatic hypertrophy or a low level prostate infection. A really high level (say >20) is highly suggestive of Ca.
A high PSA may lead to invasive and potentially harmful procedures, like biopsy, and it's clear that subjecting everyone over 50 to PSA testing will lead to many arguably unecessary biopsies. It will also lead to lots of expensive testing and even risky diagnostic procedures, at least as far as the healthcare expense beancounters are concerned. But it is also true that such testing will, in a certain number of cases, allow for the detection of early stage asymptomatic and curable prostate Ca...For those "individuals" the routine PSA testing will be life-saving.
There's another angle to all this. Prostate Ca is fairly common in older men...the incidence increases with age, and the majority of men >75 years old will have cancerous cells in their prostates. Few will die from prostate Ca. I recall our US Senator from California, Alan Cranston, who basically escaped prosecution for his being involved in the Keating Five scandal because of his prostate Ca diagnosis...he lived for many years and died of something else. There was also that Libyan Lockerbie bomber terrorist who was recently paroled from a British prison because of his prostate Ca diagnosis...So far as I know the bastard is still alive and will, like Senator Cranston, die of "old age." This doesn't mean that prostate Ca is nothing to worry about. Prostate Ca is serious business. It is particularly serious when diagnosed in younger men, where it typically presents more aggressively than in older guys. And it is this younger population that will suffer from the conclusions of this study.
For the purposes of full disclosure, I am a physician. I was aware of this study's recommendations about routine PSA testing in "younger" men, but I chose to get tested when I turned 50. The result was negative. I plan to get tested every 5 years, rtegardless of symptoms, and if my PSA becomes elevated I'll procede accordingly.
I couldn't get that bolding out. I followed with this which is where we left off:The PSA is a simple blood test. It costs money (about $100 for the test plus some more for the doctor visit). A negative test doesn't absolutely exclude prostate Ca, but for all practical purposes it does exclude it. A high PSA (>5) level is suggestive of Ca, but could be due to relatively benign things like prostatic hypertrophy or a low level prostate infection. A really high level (say >20) is highly suggestive of Ca.
A high PSA may lead to invasive and potentially harmful procedures, like biopsy, and it's clear that subjecting everyone over 50 to PSA testing will lead to many arguably unecessary biopsies. It will also lead to lots of expensive testing and even risky diagnostic procedures, at least as far as the healthcare expense beancounters are concerned. But it is also true that such testing will, in a certain number of cases, allow for the detection of early stage asymptomatic and curable prostate Ca...For those "individuals" the routine PSA testing will be life-saving.
There's another angle to all this. Prostate Ca is fairly common in older men...the incidence increases with age, and the majority of men >75 years old will have cancerous cells in their prostates. Few will die from prostate Ca. I recall our US Senator from California, Alan Cranston, who basically escaped prosecution for his being involved in the Keating Five scandal because of his prostate Ca diagnosis...he lived for many years and died of something else. There was also that Libyan Lockerbie bomber terrorist who was recently paroled from a British prison because of his prostate Ca diagnosis...So far as I know the bastard is still alive and will, like Senator Cranston, die of "old age." This doesn't mean that prostate Ca is nothing to worry about. Prostate Ca is serious business. It is particularly serious when diagnosed in younger men, where it typically presents more aggressively than in older guys. And it is this younger population that will suffer from the conclusions of this study.
For the purposes of full disclosure, I am a physician. I was aware of this study's recommendations about routine PSA testing in "younger" men, but I chose to get tested when I turned 50. The result was negative. I plan to get tested every 5 years, rtegardless of symptoms, and if my PSA becomes elevated I'll procede accordingly.
Good post and covers all the bases that we have been discussing. But it doesn't help me with the underlying dilemma: as an individual how do I balance the risk/reward? Your approach appears to rest on the intention to catch any possible cancer and treat ALL cancers. Or, at least, to do so at younger ages. The studies seem to me to be saying that overall the risks outweigh the rewards, i.e. you are individually better off risking a small chance of a bad cancer outcome to avoid a much higher chance of a bad unnecessary side effect of PSA testing/treatment. It is this choice of balance that is so difficult for many of us to sort out. Also, you don't address how (or if) the balance changes with age. For example, if I accept your premise for testing at younger ages what about when I am older. If I stayed low on the PSA scale into my mid 60s, 70s, 75... is there a point at which I should figure everybody starts getting CA at this point and treatment may not be worth pursuing (thus time to stop screening)? It seems to me that at bottom line this is not really a medical question that can be answered for us by a knowledgeable physician. It is more of a personal lifestyle question that includes evaluation of rapidly changing medical facts - I guess that often is the case with cancer. There are a lot of possible approaches to this risk/reward dilemma (test and treat at a relatively low PSA; test and treat only at a very high PSA; test and treat only with rapid acceleration; and possibly cut off testing at a given age). I would like to see more discussion about the impact of those alternatives and the risks/rewards involved.
Couldn't get that bold out either.
So, if you lasted this far, what do you think about how we should deal with this dilemma?
